Citation Nr: 9905848
Decision Date: 03/02/99 Archive Date: 03/11/99
DOCKET NO. 93-22-888 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Houston,
Texas
THE ISSUES
1. Entitlement to service connection for bilateral wrist
disorders.
2. Entitlement to service connection for bilateral foot
disorders.
3. Entitlement to a compensable rating for hemorrhoids.
4. Entitlement to a rating in excess of 10 percent for
lumbosacral strain.
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
C. Hickey, Counsel
INTRODUCTION
The veteran had active service from September 1966 to July
1969, and from September 1990 to June 1991. This appeal to
the Board of Veterans' Appeals (Board) arises from the
November 1992 rating decision of the Department of Veterans
Affairs (VA) Regional Office (RO) in Des Moines, Iowa, which
denied service connection for bilateral foot and wrist
disorders, lumbosacral strain, high blood pressure, bilateral
hearing loss, and hemorrhoids.
The case was previously before the Board in January 1996 when
service connection was granted for lumbosacral strain and
hypertension, and service connection was denied for left and
right ear hearing impairment. The remaining issues were
remanded for further evidentiary development. At that time
the Board also noted that the veteran's claim for service
connection for purposes of treatment of the residuals of
dental trauma had not been addressed and was referred to the
attention of the RO. Inasmuch as the record does not reflect
that the issue has been adjudicated during the pendency of
the remand, it is again referred to the RO for prompt action.
By a rating action in March 1996 service connection was
granted for lumbosacral strain, evaluated as 10 percent
disabling. In June 1996 the RO also granted service
connection for hemorrhoids, evaluated as noncompensably
disabling. The veteran subsequently indicated his
disagreement with the ratings assigned for his service-
connected low back disability and hemorrhoids, and increased
ratings were denied by the RO in March 1997. Supplemental
statements of the case issued in March, June, and October
1997 addressed the evaluation of those service-connected
disabilities.
By a statement received in February 1998 the veteran
expressed an intent to pursue an increased evaluation for his
service-connected hypertension. Inasmuch as that increased
rating issue has not been adjudicated by the agency of
original jurisdiction and is not "inextricably intertwined"
with the issues currently on appeal, it will not be addressed
herein, but is referred to the RO for appropriate action.
FINDINGS OF FACT
1. The claim for service connection for a bilateral wrist
disorder is not accompanied by objective medical in support
thereof.
2. The veteran has not submitted evidence sufficient to
justify a belief by a fair and impartial individual that a
chronic bilateral wrist disorder was present in service or is
otherwise related to military service.
CONCLUSION OF LAW
The veteran has not submitted a well-grounded claim for
service connection for a bilateral wrist disorder. 38
U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1998).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
Factual Background
Service medical records show that in December 1967 the
veteran complained of pain in the left hand and it was
recorded that he had a history of wrist injury without
paresthesia or numbness. The diagnosis was possible carpal
tunnel syndrome. On July 1969 physical examination for
separation from service, no pertinent complaints were noted
and no abnormalities were indicated by the examiner on
clinical evaluation.
Service medical records show that on physical examination
conducted on entry into active duty in October 1990 no
pertinent complaints or clinical findings were recorded on
clinical evaluation. In February 1991 the veteran was seen
with complaints of pain and tenderness in the left wrist.
The assessment was strained wrist. On physical examination
conducted in April 1991 the veteran gave a history painful or
trick shoulder or elbow, no related clinical findings were
noted.
Received in July 1991 was the veteran's claim for service
connection for injuries to both wrists, reportedly sustained
in the Persian Gulf.
On VA examination conducted in September 1991 the veteran
noted he had sprained both wrists in a fall while serving in
the Persian Gulf. At the time of examination his wrists
continued to hurt once in a while. Objective examination of
the wrists revealed no deformity, or pain and range of motion
was complete. X-rays revealed that both wrist joints
appeared intact with soft tissues unremarkable on x-ray. The
diagnosis was bilateral wrist sprain.
The report of his April 1993 VA examination for joints
reflects the veteran's complaint of wrist problems. He also
noted that after working he found it painful to use his
fingers to pick up an object. He indicated that pain in the
volar aspect of both wrists was greater on the left side. On
objective examination no swelling, deformity or other
impairment was found. Range of motion of the wrists was
70 degrees of dorsiflexion to 80 degrees of palmar flexion.
Wrist x-rays were negative. The diagnosis was bilateral
wrist complaints with the only objective finding being some
tenderness over the palmaris longus. It was considered that
this would go along with his history of having pain in his
fingertips when he grips. Generally a tendinitis like this,
however, was felt to be self limited with activities
modification.
When the veteran testified at his May 1993 hearing before the
Board he related that he injured his wrist in service when he
fell striking his elbows and his hands. The veteran also
testified that he did not have pain in his arms when he was
not working. In response to questioning he stated that he
based his current service connection claims exclusively on
symptoms and events noted during his second period of active
duty from September 1990 to June 1991.
VA outpatient treatment records dated in July and September
1995 show the veteran was seen with complaints referable to
the neck, left shoulder, arm and wrist since January 1995.
Medical records from a Medical Center (VAMC) dated in October
1995 demonstrate that the veteran was hospitalized for
evaluation of cervical pain syndrome. The veteran's
complaints included left-sided neck pain with radiation into
the shoulder since April 1995. Also noted was a history of
left abductor pollicis longus tendonitis (de Quervain's
syndrome) related to his job as a poultry inspector. The
veteran felt that his left arm was weak, and denied any
history of trauma or injury to his shoulder or neck.
Electromyogram (EMG) and nerve conduction studies showed
normal left median and ulnar nerve with no evidence of
radiculopathy. The veteran was evaluated by the
Rehabilitative Medicine Service who felt that, due to his job
involving constant repetitive movement, he suffered from left
de Quervain's tenosynovitis. Physical therapy was planned.
The discharge diagnosis was neck pain, likely myofascial pain
syndrome, as well as de Quervain's syndrome.
VA outpatient treatment records dated in December 1995 show
that the veteran was evaluated in neurosurgery service. At
that time the impression was de Quervain's tenosynovitis, no
neurosurgical intervention indicated.
Also of record is a private medical report signed by Jack L.
Deetjen, M.D., and dated in February 1996 which related that
the veteran was first seen in May1995 for pain in the left
hand radiating to the forearm and shoulder. It was recorded
that he had no specific injury to the wrist or thumb. The
veteran received injections in the wrist and thumbs with
temporary relief of his symptoms. Further, he had been seen
in consultation by Dr. Stewart Pipkin, in September 1995 who
felt the a C4-C5 disc protrusion revealed on magnetic
resonance imaging spectroscopy (MRI) was non-contributory
with regard to the problems of the left wrist and hand. The
pertinent diagnosis was De Quervain's stenosing
tenosynovitis, left. Dr. Deetjen indicated that the veteran
had significant disability from the disorder which would
likely be relieved with surgery. Restriction of grasping
activities by wearing a brace was recommended until he
obtained a job which did not necessitate the amount of
grasping required in his present position.
The report of an April 1996 VA orthopedic examination shows
the veteran gave a history of injury to his wrists while
serving in the Persian Gulf when he fell on his outstretched
hands. Both wrists were sore on the back at the time of the
incident. He reported to sick call and received pain
medication. Following his return from the Gulf War, the
veteran had been employed as a meat inspector which involved
repetitive activity. He developed pain in the wrist from
this repetitive movement of his fingers which radiated up
into his forearm and the left shoulder. The pain, which was
much worse on the left side, was temporary, disappearing when
he stopped the activity and shook his hands. The veteran
also reported his private physician had told him that surgery
would be required to relieve symptoms completely. On
objective examination he had normal range of motion of the
wrists, specifically, 60 degrees of dorsiflexion, 55 to 60
degrees of palmar flexion, bilaterally, with 25 to
30 degrees of ulnar deviation and radial deviation on each
side. There was some tenderness over the dorsum of the right
wrist, but no identifiable ganglion, and no tenderness over
the radial styloid or the abductor tendons of the thumb.
Finkelstein's test was negative on the right, except for some
very minimal discomfort. There was no evidence of effusion.
Examination of the left wrist showed tenderness directly over
the radial styloid and in the first dorsal compartment, and a
positive Finkelstein's test, compatible with stenosing
tenosynovitis or de Quervain of the left thumb tendons.
There was tenderness directly on this area and on other
tenderness within the wrist itself. Compression of the
wrists and traction on the wrists bilaterally did not cause
pain and the veteran had full pronation and supination
bilaterally. There was no pain on pressure over the
navicular bones on either wrist. The examiner's impression
was that the veteran had bilateral wrist sprains when he fell
in Saudi Arabia and which were probably pretty well cleared
up. Subsequent to that he had been working with the
repetitive activity with both hands and had developed de
Quervain's stenosis tenosynovitis bilaterally much worse on
the left than the right. This would explain tenderness
directly over that specific area and the repeated injections
by the civilian physician, reported by the veteran. It would
also explain why he needed surgery for compartment release.
The examiner stated he did not consider that the stenosing
tenosynovitis of the wrist was related to any injury that the
veteran sustained in service, but rather it was a direct
result of the work that he was presently doing as described
to the examiner. The de Quervain's developed after the fall
in service and the examiner did not at all relate that
disorder to the service-connected fall on his hands.
Bilateral wrist x-rays were normal with the exception of
small cyst formation in the lunate of both arms.
VA outpatient treatment records show that when the veteran
was seen in October 1996 for unrelated complaints, it was
noted that the veteran was unemployed secondary to surgery
for repetitive trauma and de Quervain's release. When he was
seen in January 1997 for multiple complaints the veteran
indicated that he had cramps when holding/gripping too tight.
Analysis
The veteran contends that he has chronic disorders of both
wrists which were caused by injuries he reportedly sustained
during his service in the Persian Gulf. Service connection
connotes many factors, but basically it means that the facts,
as shown by evidence, establish that a particular injury or
disease resulting in disability was incurred coincident with
service in the Armed Forces, or if preexisting such service,
was aggravated therein. 38 U.S.C.A. §§ 1110, 1131, 1153 (West
1991). Such a determination requires a finding of a current
disability which is related to an injury or disease incurred
in service. Watson v. Brown, 4 Vet.App. 309, 310 (1993);
Rabideau v. Derwinski, 2 Vet.App. 141, 143 (1992).
Service connection may be granted for any disease diagnosed
after discharge, when all the evidence, including that
pertinent to service, establishes that the disease was
incurred in service. 38 C.F.R. § 3.303(d)(1998).
Alternatively, under 38 C.F.R. § 3.303(b), service connection
may be awarded for a "chronic" condition when; (1) a
chronic disease manifests itself and is identified as such in
service (or within the presumption period under 38 C.F.R.
§ 3.307 (1998)) and the veteran presently has the same
condition; (2) a disease manifests itself during service (or
during the presumptive period) but is not identified until
later, there is a showing of continuity of symptomatology
after discharge, and the medical evidence relates the
symptomatology to the veteran's present condition. Rose V.
West, 11 Vet. App. 169 (1998); Savage v. Gober, 10 Vet. App.
488, 495-98 (1997).
Each disabling condition as shown by a veteran's service
records, or for which he seeks service connection, must be
considered on the basis of the places, types and
circumstances of his service as shown by service records, the
official history of each organization in which he served, his
medical records and all pertinent medical and lay evidence.
38 U.S.C.A. § 1154.
A claimant for benefits under a law administered by the
Secretary of the Department of Veterans Affairs (VA) shall
have the burden of submitting evidence sufficient to justify
a belief by a fair and impartial individual that the claim is
well grounded. The Secretary has the duty to assist a
claimant in developing facts pertinent to the claim if the
claim is determined to be well grounded. 38 U.S.C.A.
§ 5107(a). Thus, the threshold question to be answered is
whether the veteran has presented a well grounded claim; that
is, a claim which is plausible. If he has not presented a
well grounded claim, his appeal must fail, and there is no
duty to assist him further in the development of his claim as
any such additional development would be futile. Murphy v.
Derwinski, 1 Vet.App. 78 (1990).
As explained below, the Board finds that the appellant's
service connection claim is not well grounded. To sustain a
well grounded claim, the claimant must provide evidence
demonstrating that the claim is plausible; mere allegation is
insufficient. Tirpak v. Derwinski, 2 Vet.App. 609 (1992).
The determination of whether a claim is well grounded is
legal in nature. King v. Brown, 5 Vet.App. 19 (1993). A
well-grounded claim is one which is meritorious on its own or
capable of substantiation. Such a claim need not be
conclusive but only possible to satisfy the initial burden of
38 U.S.C.A. § 5107(a). Murphy v. Derwinski, 1 Vet.App. 78,
81 (1990). Where the determinative issue involves either
medical etiology or a medical diagnosis, competent medical
evidence is required to fulfill the well-grounded claim
requirement of 38 U.S.C.A. § 5107(a). Lathan v. Brown, 7
Vet.App. 359 (1995). In order for a claim for service
connection to be well grounded, there must be competent
evidence of a current disability (a medical diagnosis), of
incurrence or aggravation of a disease or injury in service
(lay or medical evidence) and of a nexus between the in
service injury or disease and the current disability (medical
evidence.) The nexus requirement may be satisfied by a
presumption that certain diseases manifesting themselves
within certain prescribed periods are related to service.
Caluza v. Brown, 7 Vet.App. 498 (1995).
The evidence in this case shows that the veteran was treated
on one occasion during his first period of active service for
left hand pain, with a diagnosis of possible carpal tunnel
syndrome, and no related complaints or findings were noted on
examination at separation from service. During his second
period of active duty he was treated for strained wrist.
Again no findings were noted on separation examination.
Although a diagnosis of bilateral sprained wrist was noted on
VA examination in September 1991 only normal findings were
recorded on clinical examination at that time. Currently,
the record reflects problems with his wrist are related to
the condition diagnosed as de Quervain's stenosing
tenosynovitis. However, the earliest medical evidence of the
current disorder was noted in 1993 nearly two years after his
second period of active service. Moreover, the veteran has
presented no medical evidence or opinion to demonstrate that
his current disorder is related to any symptoms or events
noted in service. Rather, multiple physicians who have
evaluated him, both VA and non VA have concluded that de
Quervain's stenosing tenosynovitis is caused by the
repetitive grasping activity the veteran experienced in his
job as a poultry inspector. In fact the VA examiner in April
1996 specifically found that there was no relationship to any
injury in service, noting that the sprains were likely
cleared up and the current disorder had onset well past the
time of separation from service.
Although evidentiary assertions by the veteran must be
accepted as true for the purposes of determining whether a
claim is well-grounded, the exception to this principle is
where the evidentiary assertion is inherently incredible or
when the fact asserted is beyond the competence of the person
making the assertion. King v. Brown, 5 Vet.App. 19, 21
(1993). This exception applies to the veteran's lay
assertions that his current symptoms are etiologically
related to the injury in service, because lay persons (i.e.,
persons without medical training or expertise) are not
competent to offer opinions concerning medical causation.
Moray v. Brown, 5 Vet.App. 211 (1993); Grottveit v. Brown, 5
Vet.App. 91 (1993); Espiritu v. Derwinski, 2 Vet.App. 492
(1992). Although we do not doubt the sincerity of veteran's
assertions, in the absence of any supporting medical evidence
or opinion, he has not presented the elements of a plausible
claim for service connection.
ORDER
The claim for service connection for bilateral wrist
disorders is denied as not well-grounded
REMAND
On review of the record the Board notes that subsequent to
the most recent VA examination for hemorrhoids, the veteran
was seen in outpatient treatment, to include a flexible
sigmoidoscopy conducted in January 1997 for indications of
microcytic anemia, and possibly chronically bleeding
hemorrhoid. Although an internal hemorrhoid was revealed by
that study, subsequent treatment records dated in April 1997
indicated microcytic anemia, internal hemorrhoid with a
differential diagnosis of sickle cell. When the veteran was
seen in June 1997, he denied hemorrhoids and in September
1997 the assessment was microcytic anemia, of unknown
etiology, possible hemoglobinopathy. In view of the
foregoing, further medical evaluation is required to assess
the nature and extent of the manifestations of the veteran's
service-connected hemorrhoids.
With regard to the veteran's claimed bilateral foot disorder,
recent VA medical examinations have reflected widely varying
and somewhat ambiguous conclusions concerning the nature and
etiology of foot symptoms. Most recently, on podiatric
examination in April 1996 the assessment was 1. Plantar left
calcaneal heel spur syndrome with lateral periosteal
tenderness pattern. 2. Sublease metatarsal head
bursitis/capsulitis/overuse without ongoing stress reaction.
The fat pad was well preserved and the adjacent joints were
nontender, suggesting that this complaint was incidental to
the 1990-91 service activities without a causal relationship
between the current complaint and the earlier service. 3.
Pressure hyperkeratotic lesion about the fifth metatarsal
head weight-bearing regions of both feet. 4. Generally
successful surgery to the fourth and fifth toes of both feet
with patchy neurotmesis/small branch neurotmesis leading to
perception of anesthesia about the fifth toes. 5. The
patient's complaint of numbness in the lower extremities with
sitting was considered likely positional sciatic nerve
impingement, not warranting extensive work up. By contrast,
the diagnosis in April 1993 was bilateral pes planus, mild to
moderate in clinical severity, and although the veteran was
treated for foot pain during service, on VA examination in
September 1991, three months after separation, the diagnosis
was status post surgery right foot with complaint of pain,
both feet, normal examination. The Board concludes that
additional medical clarification is required in this regard.
The record also reveals that the most recent VA examination
for low back disability was conducted in April 1993.
Subsequently, the veteran underwent laminectomy at the L5,
and L5-S1 diskectomy, due to herniated nucleus pulposus in
May 1994. Since that time he has been in treatment for
chronic low back pain with radiation of pain and numbness in
the lower extremities. In view of the passage of time, and
intervening treatment, the Board finds that a contemporaneous
examination is warranted to ensure a fully informed decision
regarding the evaluation of the veteran's service-connected
back disability.
In this regard the Board notes that in DeLuca v. Brown, 8
Vet.App. 202 (1995), the United States Court of Veterans
Appeals (Court) directed that a VA rating examination must
adequately portray functional loss due to pain, weakened
movement, excess fatigability or incoordination. In DeLuca,
the Court held that ratings based on limitation of motion do
not subsume 38 C.F.R. § 4.40 (1994) or 38 C.F.R. § 4.45
(1994). It was specified that the medical examiner should be
asked to determine whether the joint in question exhibited
pain, weakened movement, excess fatigability or
incoordination and that the determinations, if feasible,
should be expressed in terms of the degree of additional
range-of-motion loss due to any pain, weakened movement,
excess fatigability or incoordination. It was also held that
the provisions of 38 C.F.R. § 4.14 (1994) (avoidance of
pyramiding) do not forbid consideration of a higher rating
based on greater limitation of motion due to pain on use,
including during flare-ups.
Up-to-date treatment records should also be compiled on
remand. In this regard it is noted that although the veteran
has indicated treatment at the VAMC in Richmond, Virginia,
from 1978 to 1980, and the VAMC at Memphis, Tennessee,
during the period 1981 to 1977 (sic), it is not clear from
the claims folder whether efforts were undertaken to obtain
the records of that treatment, which should be accomplished
on remand.
Accordingly, the case is REMANDED for the following actions:
1. The RO should contact the veteran and
request that he submit the names and
addresses of all health care providers,
VA or private, who have evaluated or
treated him for his low back disability,
foot symptoms, or hemorrhoids since
August 1997. After securing the
necessary releases, the RO should request
copies of any previously unobtained
pertinent medical records for association
with the claims folder. Additionally,
special requests should be made to the
VAMC in Richmond for records of treatment
from 1978 to 1980, and the Memphis VAMC
for treatment records dated in the 1970's
and 1980's.
2. Following completion of the above
requested development, the veteran should
be scheduled for special VA orthopedic
and neurological examinations to assess
the nature and extent of his low back
disability. The examiners must
thoroughly review the claims folder, to
include a copy of this remand, prior to
evaluating the veteran. All indicated
tests and studies should be performed, to
include full range of motion studies,
expressed in degrees. The examiners
should clearly set forth all clinical
findings which are attributed to the
service-connected disability.
Additionally the orthopedic examiner
should provide the following opinions
based upon the medical evidence of
record. The examiner should be asked to
provide an opinion as to whether the
veteran's lumbosacral spine exhibits
weakened movement, excess fatigability,
or incoordination attributable to the
service connected disability; and, if
feasible, these determinations should be
expressed in terms of the degree of
additional range of motion loss due to
any weakened movement, excess
fatigability, or incoordination. The
examiner should also provide an opinion
as to whether pain could significantly
limit functional ability during flare-ups
or on repeated use over a period of time.
This determination should if feasible, be
portrayed in terms of the degree of
additional range of motion loss due to
pain on use or during flare-ups. In the
event that any opinion requested is not
medically feasible the examiner should so
state and explain the basis of that
determination.
3. The veteran should also be scheduled
for a special podiatric examination to
assess the nature and etiology of all
findings referable to the feet. The
examiner must thoroughly review the
claims folder to include a copy of this
remand prior to evaluating the veteran.
All indicated special tests and studies
should be conducted and all clinical
findings and diagnoses set forth in the
report. To the extent possible the
examiner should also provide an opinion
based upon the medical evidence of record
as to whether it is at least as likely as
not that the veteran has any chronic
disability of either or both feet which
is etiologically related to active
service. If so, the symptoms and
findings attributable to the service-
connected disorder should be clearly
distinguished from those considered to
result from unrelated causes. All
opinions should be supported by reference
to the evidence.
4. Additionally, the veteran should be
scheduled for a special VA examination to
assess the nature and extent of the
manifestations of hemorrhoids. The
examiner must thoroughly review the
claims folder, to include a copy of this
remand, prior to evaluating the veteran.
All indicated special tests and studies
should be conducted and all clinical
findings clearly set forth in the
examination report. The examiner should
specifically indicate whether the veteran
has anemia and if so whether it is at
least as likely as not attributable to
his hemorrhoids. The examiner also
should state whether hemorrhoids, if
present, are large, thrombotic or
irreducible, and whether they are
characterized by excessive redundant
tissue, persistent bleeding, or fissures.
The frequency of recurrences should be
indicated if applicable.
4. Following the completion all above
requested actions the RO should review
the veteran's claims for service
connection for a bilateral foot disorder
and increased rating for hemorrhoids, and
low back disability, on the basis of all
evidence of record, and all applicable
law and regulations. If any action taken
remains adverse to the veteran he and his
representative should be provided a
supplemental statement of the case and an
appropriate period to respond.
Thereafter, subject to current appellate procedures, the case
should be returned to the Board for further appellate
consideration, if appropriate. The appellant need take no
action until otherwise notified, but he may furnish
additional evidence and argument while the case is in remand
status. Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992);
Booth v. Brown, 8 Vet. App. 109 (1995). The purpose of this
REMAND is to obtain additional information and to ensure due
process of law. No inference should be drawn regarding the
final disposition of the claim as a result of this action.
This claim must be afforded expeditious treatment by the RO.
The law requires that all claims that are remanded by the
Board of Veterans' Appeals or by the United States Court of
Veterans Appeals for additional development or other
appropriate action must be handled in an expeditious manner.
See The Veterans' Benefits Improvements Act of 1994, Pub. L.
No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A.
§ 5101 (West Supp. 1996) (Historical and Statutory Notes).
In addition, VBA's ADJUDICATION PROCEDURE MANUAL, M21-1, Part
IV, directs the ROs to provide expeditious handling of all
cases that have been remanded by the Board and the Court.
See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03.
C.W. Symanski
Member, Board of Veterans' Appeals
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
Supp. 1995), a decision of the Board of Veterans' Appeals
granting less than the complete benefit, or benefits, sought
on appeal is appealable to the United States Court of
Veterans Appeals within 120 days from the date of mailing of
notice of the decision, provided that a Notice of
Disagreement concerning an issue which was before the Board
was filed with the agency of original jurisdiction on or
after November 18, 1988. Veterans' Judicial Review Act,
Pub. L. No. 100-687, § 402 (1988). The date that appears on
the face of this decision constitutes the date of mailing and
the copy of this decision which you have received is your
notice of the action taken on your appeal by the Board of
Veterans' Appeals. Appellate rights do not attach to those
issues addressed in the remand portion of the Board's
decision, because a remand is in the nature of a preliminary
order and does not constitute a decision of the Board on the
merits of your appeal. 38 C.F.R. § 20.1100(b) (1998).
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